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City to Explore a Way to Add Organ Donors

By CARA BUCKLEYPublished: June 1, 2008

New York City is pioneering a potential solution to a supply-and-demand problem that has long vexed doctors the world over: how to meet a desperate need for donated organs without trampling on sensitivity surrounding the sanctity of death.

About a third of all donated organs are harvested from live donors. Nearly all the rest come from people who have been declared brain dead while undergoing treatment in hospitals. But thousands of people die at home or on the street, their organs almost never considered for transplantation even if they had filled out donor cards, because there is no system in place to handle it.

But with a $1.5 million grant over three years from the federal Health Resources and Services Administration, a team of medical experts and bioethicists is looking to expand the city’s donor pool by deploying a “rapid organ-recovery ambulance” to collect and preserve the organs of people who die of cardiac arrest. The plan — modeled on a successful program in Spain — is for the ambulance to trail regular ambulances that try to save people’s lives, then to swoop in if patients die and to maintain the bodies in stasis for several hours at a hospital, until family members can decide whether to donate the organs.

“I see this as a continuum for saving lives,” said Dr. Lewis R. Goldfrank, director of emergency medicine at Bellevue Hospital Center, who is leading the project. “To see people die every year who are waiting on organ-donor lists and people die who are potential donors, seems a mismatch between societal needs and societal values.”

Dr. Goldfrank aims to get the first organ-recovery ambulance in operation by year’s end in Lower Manhattan. If the project is a success and replicated in other cities, he estimated that the nation’s donor pool could grow by 22,000 people.

News of the federal grant was reported last month in The Washington Post and USA Today. Details are still being hammered out as Dr. Goldfrank and others meet with community and religious leaders to assuage public jitters.

“In our culture, doing things to a dead body without consent is highly controversial, even if it’s minor, even if doesn’t cause permanent marking,” said Dr. Arthur Caplan, a bioethicist at the University of Pennsylvania who is not involved in the program.

“There are a lot of Americans who have a hard time getting into a hospital because they don’t have insurance or they have poor insurance,” Dr. Caplan noted. “They will not necessarily find it a good thing when they find out that they can’t get into the hospital, but that a hospital will send a special ambulance to bring their body to the hospital when they’re dead.”

New York’s recovery ambulance is inspired by a donor-detection program started in 1989 in Spain, which now has the highest organ-donation rate in the world. In the past two decades, Spain has tripled organ donation to 35 donors per million people, significantly shrinking its waiting list. In the United States, there were 23 donors per million people in 2007, according to the organization Donate Life America, with roughly 99,000 people waiting.

But thousands of organs from would-be donors are never harvested because there is no system to quickly transplant organs from victims of cardiac arrest.

“There are times where a family member of the newly deceased wanted the opportunity to donate the organs, and in the current system they don’t have that opportunity,” said Dr. Bradley Kaufman, a medical director with the Fire Department. “The main goal of the project is to preserve the right for the family to make that decision.”

Dr. Kaufman said the new system would not affect resuscitation efforts, only what would happen if those measures failed.

A typical situation, according to several of the doctors involved, might unfold like this: Emergency services are notified that a person has gone into cardiac arrest. An ambulance is dispatched, and normal efforts are made to revive the victim. Unbeknownst to paramedics in the first ambulance, the dispatcher would also have alerted the organ-recovery ambulance, which would also head to the scene. The medics on the second ambulance would not get involved unless all resuscitation efforts were exhausted and the victim declared lifeless.

At that point, instead of transporting the body to a funeral home or the medical examiner’s office, the organ-recovery team would wait five minutes, then begin running fluids into the body to preserve organs and prevent blood clots. A medic would administer chest compressions to maintain minimal blood flow, and the body would be taken to hospital. Transplants would happen only if the next of kin agreed and organs were healthy.

A similar project, financed by the same federal agency, is under way at the University of Pittsburgh School of Medicine, though it will be limited to people who die in hospital emergency rooms.

“I applied for the grant out of my conviction that we can do better for dying patients,” said Dr. Michael DeVita, a professor of critical care medicine at the university. “I’m an I.C.U. doctor, and I want people at the end of their life to have the best care possible, for both the patient and the family. And that also involves enabling people to build a legacy that they can leave behind.”